Protocol for stable angina: new diagnosis



Protocol for stable angina: new diagnosis

First contact: GP

• History ( for reference see BHF factfile 05/2000 ): record onset, frequency, level of exertion at which angina occurs, rest pain and when rest pain last occurred.

• Examination: check pulse, BP, heart sounds, apex beat, carotids, JVP, ankles and chest ( looking for dysrhythmia, aortic and carotid stenosis, heart failure, cardiomyopathy, anaemia and thyroid dysfunction ).

• Symptomatic relief: Sublingual nitrates, Beta-blocker ( first choice: tolerated best plus improvement in outcome ), if contraindicated calcium antagonist or oral nitrates

• Aspirin 75mg daily ( if not tolerated or contraindicated consider Clopidrogel )

• Emergency advice: education about symptoms of heart attack ( chest pain lasting more than 20min and not relieved by sublingual nitrates ) and instruction to seek help rapidly by calling 999.

• Arrange Exercise ECG ( see appendix 1 ).

• Referral to practice nurse ideally same day or at least within 48hrs.

Second contact: Practice Nurse

• Take blood: Hb, random plasma glucose, TFTs, random serum cholesterol, U/Es

• Record 12 lead resting ECG.

• Measure height, weight and record BMI.

• Supply written information on coronary heart disease.

• Smoking cessation advice if necessary

• Dietary advice ( cholesterol low diet, oily fish, 5 portions of fruit and vegetables / day, alcohol)

• Advice on weight reduction as appropriate.

• Advice that light exercise like walking to a level not causing angina does not harm ( stable angina only ).

• Advice about driving: driving must cease when symptoms occur at the wheel or at rest, driving may recommence when satisfactory symptom control is achieved, DVLA need not be notified. Group 2 drivers: refusal or revocation with continuing symptoms treated or untreated – must be free of angina for 6 weeks and exercise testing met the criteria. )

GP review: ( after one week as appropriate )

• Enquire about angina ( any more episodes, how frequent, any rest pain )

• Enquire about medication concordance and side effects.

• Check pulse and blood pressure.

• Adjust medication according to symptoms: increase beta-blocker ( eg Atenolol from 50mg to 100mg ) or other antianginal used in first instance before adding second antianginal ( unless there is a good reason not to do so like profound bradycardia ).

• Check ECG result.

• Check blood results:

• Especially enforce dietary advice and introduce statin as necessary ( aim is to reduce serum cholesterol either to less than 5mmol/l ( LDL-c to below 3mmol/l ) or by 30% whichever is greater). A statin can be started without assessing a dietary response if the total-cholesterol is above 6 mmol/l.

• Advice and treatment of blood pressure to below 140/85 mmHg.

• Arrange for a blood test in 4-5 weeks with practice nurse / assistant: fasting lipid profile ( unless the patient had this done on his initial nurse contact in which case a total cholesterol is sufficient )

Next review by doctor:

guided by symptoms: if angina is controlled patient should be reviewed after 6 weeks ( exercise test result should be available by then ).

• Discuss test result with patient ( see appendix 2 ).

• If not already done make sure correct disease code ( G3.. ) is entered on computer.

• Again enquire about angina and medication.

• Adjust antianginal and antihypertensive medication as required.

• Adjust statin dose according to blood results.

• If all satisfactory make diary entry for ischaemic heart disease review in 6 months with practice nurse.

Appendix 1: the exercise ECG is important as it gives diagnostic as well as prognostic information. This will largely determine if somebody needs angiography. Therefore anybody with new symptoms suggestive of angina should have an exercise ECG. This can be done via the Rapid Access Chest Pain Clinic. Patients whose symptoms are not characteristic of angina should not be referred for an exercise ECG directly because of a relative high false positive rate and should rather be referred for an opinion to a caridiologist. Patients who are physically incapable of walking on a treadmill should be referred for Thallium scanning via the cardiology department. Special considerations have to be given to patients with a heart murmur as aortic stenosis would be a contraindication to exercise testing as well as uncontrolled hypertension. Patients with rest pain are classed as unstable angina and should not be referred for exercise testing. If occurring in last 48 hrs hospital admission should be considered. In other cases an urgent referral to a cardiologist should be made.

Appendix 2: result of exercise ECG should receive a coded entry on EMIS ( 3213.. ) by Angela / Fiona.

Appendix 3: Beta-blockers use either Atenolol or Bisoprolol. As statins use Simvastatin, Pravastatin or Atorvastatin. As calcium channel blocker use preferably a rate limiting one like Diltiazem if not contraindicated. If a non rate limiting calcium channel blocker is wanted use a slow release Nifedipine preparation because of cost as suggested by the PCT.

Annual Review of stable angina

System

Clerical role:

• Generate monthly list of patients to invite for review ( usually annually )

• Use diary recall system on EMIS computer software ( code 68B2: caridiovascular clinic )

• Generate list of patients each months who DNA

• Record morbidity from hospital letters relating to CHD using agreed READ codes ( see section read codes )

Nurse Role:

• Practice nurse competent in care of patients with CHD

• Carrying out annual review using a standardised protocol: Cardiovascular Clinic Template.

• Refer patients of concern to GP and patients on suboptimal treatment

• Follow up of patients who DNA

• Liaise with support groups eg. Cardiac liaison nurse, Heartsmart, Healthwise, BEEP

• Ensure available supply of patient literature

• Annual audits

GP role

• Refer patients to practice nurse for annual review using the diary recall system.

• Support nursing team and see patients of concern identified by nursing team

• Ensure patients medication review

• Liaise with secondary care.

• Ensure morbidity is highlighted on hospital letters to enable clerical staff to read code

• Ensure new diagnosis of CHD ( and CVD ) is read coded

Cardiovascular Clinic

Carried out primarily by our experienced nursing team during Practice Nurse surgeries with 20 min per appointment.

One week prior to the appointment the patient is invited to attend our practice nurse assistant for obtaining a fasting blood sample for cholesterol and TG, U/Es, Glucose, LFTs and FBC ( modified as necessary ).

The review is structured using our ‘Cardiovascular Clinic’ template.

Symptom and History review:

Angina: record frequency and ask especially for an increase in frequency, severity, need for medication and reduction in exercise tolerance. Ask for symptoms at rest.

Unstable angina ( see definition ) = immediate referral to GP

Also ask for SOB, intermittent claudicatio, oedema and impotence.

Review and update personal and family history ( advice patients under 65 to have their families ie. first degree relatives over 18 screened for CHD risk factors ).

Medication Review:

• Ask for side effects.

• Check concordance.

• Make sure patient receives Aspirin or Clopidrogel alternatively. Ensure Aspirin CI is recorded. If on Warfarin record Aspirin CI too.

• Make sure patient receives beta-blocker or record CI.

• Ensure patient receives lipid lowering therapy to achieve a total-cholesterol of < 5 mmol/l or LDL of < 3 mmol/l ( or lowered by 30% whichever is the greatest ). If CI record it.

• Ask for use and frequency of nitrtaes. Ensure patient is equipped with a fast short acting nitrate and knows how to use it. Point out short lifespan of these products and to check expiry dates.

• Refer any patients with inappropriate medication or suboptimal treatment to the GP.

Observations

• Check blood results and refer to GP if of concern.

• Pulse - arrhythmias should be referred to GP.

• BP - if >140/85 see hypertension protocol

• Weight, height and BMI.

Risk factor assessment

• Record smoking status. Aim for smoking cessation and refer motivated patients to SCA.

• Record activity level. Aim to increase activity gradually ( dependant on limitations of angina ). Moderate activity of 20 – 30 min five times per week is recommended as an ongoing goal but any increase in activity is beneficial. Refer to BEEP scheme as appropriate and see exercise protocol for details and safety adivice.

• Dietary habits. Aim for a reduction in saturated fat and shift towards carbohydrates, at least 5 portions of fruit and vegetables per day, increase fibre intake, increase oily fish intake and reduce salt and sugar. Use ‘Rate your diet’ quiz and ‘Eating for a Healthy heart’ information sheet.

Educate

• Patients must know how to recognise the symptoms of a heart attack ( see new diagnosis above ) and to seek immediate help by telephoning ‘999’.

• Patient must know about unstable angina and its significance ie this has to be reported to the GP immediately.

• Explore patients health beliefs and concerns around CHD taking employment issues and benefits into consideration as well.

• Ensure patient has written information on CHD.

Follow-up

The use of the Follow-up prompt in the template will automatically create a diary entry used for the recall lists. The usual interval is one year but has to be adjusted according to patients needs.

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